Garrett on Global Health

April 3, 2017

Dear Friends and Colleagues,

Events have moved so swiftly of late that every day brings political revelations, each of which seem worthy of comment in this space. It is easy to lose sight of what is important amid the din.

 

In Washington, the Donald J. Trump administration issued its budget blueprint, calling for complete elimination of many agencies and programs that play a role in global health, development, environmental science and protection, biomedical research, diplomacy and climate negotiations, to name a few. Overall, President Trump seeks to dramatically increase funding for military and homeland security, stabilize Social Security and other major entitlements, and slash discretionary spending by as much as 100 percent. Read my detailed analysis of the so-called skinny budget.

In my interpretation of Trump’s budget plans, I analyzed statements in the document along with comments made by the president, all of which indicated continued support at 2017 levels of the President’s Emergency Plan for AIDS Relief (PEPFAR), tuberculosis (TB), and malaria programs. I was taken to task by Devex writer Michael Igoe, who wrote that nothing was assured, and the future of HIV, TB, and malaria support remains in doubt. Congress and White House are now focused on tax reform, and a detailed budget fight will likely unfold in late spring or early summer. Until then, no one can know for sure how the House and Senate Republicans will handle President Trump’s blueprint.

Before March 24, most political speculators would have assumed that a very conservative Republican Party controlling both houses of Congress meant smooth sailing for White House requests. But on March 24, the party essentially imploded, as its various legislative factions and the White House fought bitterly for passage of the American Health Care Act (AHCA, often called “Trumpcare”). President Trump ordered House Speaker Paul Ryan (R-WI) to corral his Republican troops for a successful vote, but the far-right Freedom Caucus within the party demurred. Trump recognized defeat, and called on Ryan to pull the AHCA from voting. Ryan ended the volatile day by telling the press that “Obamacare is the law of the land for the foreseeable future.”

For a riveting account of the AHCA battle, and other action in Washington, I recommend viewing The Circus, a weekly Showtime documentary series that lets the camera do most of the talking, offers little punditry, and takes the viewer behind the scenes in a blow-by-blow look at American politics.

The AHCA would have been disastrous for many reasons, including the likely loss of health coverage for twenty-four million Americans, and I applauded its death. But, in my opinion, the least noted element of the bill was perhaps the most potentially devastating: it targeted the $1 billion budget for prevention programs at the Centers for Disease Control and Prevention (CDC). This constitutes 12 percent of the CDC’s overall budget, including global disease surveillance efforts.

The failure of the AHCA revealed chasms within the Republican Party that some political observers have predicted will affect every major Trump initiative, from budget battles to foreign policy. The president’s job approval ratings have fallen dramatically, currently rendering him the least-liked first-year president in the history of American polling. Although it is ill-advised to try to predict the rest of 2017 in Washington, it does seem wise to look at the legislative future with an open mind. On the down side, the failure of the AHCA does not equal success for the Affordable Care Act, and Trump has argued that the existing health law is in “a death spiral” and will fail on its own. The facts do not bear out such prognostication, assuming the ACA continues to be executed as it was under President Barack Obama. But there are countless ways that Health and Human Services Secretary Tom Price could make surgical strikes around the edges of the ACA and Congress could nibble away at the provisions of the law that move funding to the states through Medicaid, deliberately pushing the ACA into the forecast death spiral. Whether these tactics will be implemented depends on a political calculus among Republican leaders over whom midterm election voters will blame if they cannot afford surgery or their loved ones lose insurance coverage.

Republican Vice-Presidential candidate and Wisconsin representative Paul Ryan (R-WI) speaks at the Values Voter Summit in Washington September 14, 2012. (Reuters/Gary Cameron)

Another area of likely contention within the Republican Party is science. Trump’s budget blueprint calls for the most extreme cuts seen to the National Institutes of Health basic research budget since World War II, along with complete elimination of the Fogarty Institute (which deals with global health issues), a host of foreign scientists’ diplomacy and sponsorship programs, much of the National Laboratories’ budgets, and every climate change and environment research program in the federal government. Recently, the White House indicated that President Trump sees no need for a science advisor, and he may eliminate the White House Office of Science and Technology Policy (OSTP). President Obama gave science an unparalleled role: his science advisor was seated in morning security briefings, a Nobel laureate served as his first secretary of the Department of Energy, and climate change analysis was front and center in the White House. Perhaps in reaction, Trump shows nothing but disdain for science and scientists.  He is the only president since Franklin D. Roosevelt to start his term in the Oval Office without in-house science advice. Since Harry Truman created the role in 1950, almost every White House has featured a robust OSTP and a science advisor. Only Richard M. Nixon went without a science advisor, choosing not to replace Edward E. David Jr. when David resigned in protest over the president’s policies in 1973. A year and a half later, President Nixon himself resigned following the Watergate crisis revelations.

On Capitol Hill, prominent Republicans want to hold hearings in which climate change deniers are given a stage to decry every assertion about fossil fuel–driven CO2 elevation and human-caused climate change. Other Republican politicians hope to wage an attack on science, writ large, questioning everything from Darwin’s theory of evolution to the wisdom of vaccinating children. Still, the Republican Party is far from united in assaulting the underpinnings of science and challenging the budgets for biomedical research.

American scientists plan to stage protest marches across the country on April 22. If the protests materialize in significant form, they will signify the largest public outcry ever staged by American scientists. Of course, things could be worse—consider Brazil, where scientific institutions appear to be crumbling so rapidly that scientists are fleeing the country in search of greener pastures. And scientists in the United Kingdom are extremely nervous about the future of their enterprises, now that Prime Minister Theresa May has formally invoked Article 50 and the United Kingdom is irreversibly on its path toward exit from the European Union.

I recently published an analysis of the links between globalization and cross-national efforts such as the pursuit of science, climate change mitigation, international health campaigns, pandemic fights, and humanitarian responses. “Global Health in a Populist and Nationalist Age” appeared in a special seventieth anniversary publication of Columbia University’s School of International and Public Affairs’ Journal of International Affairs.

The new nationalism in the West has not yet faced a pandemic test. Threats do, however, loom: the Zika virus; yellow fever spreading from Amazonia outward across Brazil, Columbia, and Bolivia; the highly pathogenic H7N9 influenza claiming human lives this season in China; and the even more lethal H5N1 flu spreading in Southeast Asia. I prepared an expert brief for the Council on Foreign Relations assessing the H7N9 threat, which has expanded in the month since the brief was posted, now claiming the largest human death toll since its original 2009 emergence.

Today I posted a second expert brief for CFR, coauthored with Ramanan Laxminarayan, director of the Princeton Environmental Institute. We examine the recent designation by the World Health Organization (WHO) of twelve bacterial diseases as special threats to humanity due to antibiotic resistance, and we take a deep dive into plasmid-carried extreme drug resistance (with the NDM and mcr plasmids) and the end of curable bacterial infection. We share our concern that actions taken to date to limit drug resistance reflect little more than rhetorical political policy, and that continued unfettered distribution of antibiotics as livestock growth promoters dooms humanity to an end of the age of antibiotics. 

The impact of antibiotics on the environment, wreaking havoc in microbiomes from the human gut to the deep seas, is one of the elements of the planetary health movement rising now in public health circles. Following Trump’s inauguration, the CDC cancelled long-standing plans to convene a planetary health summit in Atlanta focusing on the impact of climate change. The meeting convened instead at the Carter Center in Atlanta, chaired by former Vice President Al Gore. I attended the gathering, which was remarkable for bringing together a wide range of expertise, from Native American environmental activists to soil scientists focused on crop yields amid rising Earth surface temperature. In the meeting, Gore deliberately set a very positive tone, summarizing sessions with hopeful spins. The Nobel Peace Prize winner’s new movie, An Inconvenient Sequel, approaches climate change from a significantly more alarming perspective.

As long as I am mentioning movies, on April 7, CNN will air a new feature, Unseen Enemy, in which I participated. The film, produced by Janet Tobias and Vulcan Pictures, looks at the rise of infectious diseases and high pandemic risk potential for coming years. Also featured in the film are individuals well known to most of my readers: Peter Piot, Jeremy Farrar, Heidi Larsen, Mark Smolinski, and Larry Brilliant.

In the film, I try to draw links between climate change, anthropogenic inputs, and increased pandemic threat. The planetary health agenda, I contend, has its best chance of garnering support in today’s London and Washington if it draws connections to emerging globalized diseases. I struck a similar note in a recent speech to the Rockefeller Foundation, and I will continue to sound these themes when I speak in Oxford on April 6 at the Skoll World Forum and on April 14 at Northeastern University in Boston in a keynote speech to its annual health law conference, this year entitled, “Between Complacency and Panic: Legal, Ethical, and Policy Responses to Emerging Infectious Disease.”

Looking ahead, the World Health Assembly in Geneva in May will witness the first all-country-voting election for director general in the seven-decade history of the World Health Organization. The three candidates (Sania Nishtar of Pakistan, Tedros Adhanom Ghebreyesus of Ethiopia, and David Nabarro of the United Kingdom) are now campaigning vigorously on social media, on the lecture circuit, and behind the scenes in meetings with ministers and secretaries of health worldwide. A month ago, it was hard to see many policy differences between the three, but their respective priorities are coming into sharper focus as the May 22 election week looms. All three are using Twitter and Facebook aggressively—global health advocates are advised to follow their streams: @SaniaNishtar, @DrTedros, and @davidnabarro.

On March 3, I convened a roundtable at CFR, “Governing Global Health in Stormy Seas.” The meeting, which was on the record, featured Chelsea Clinton, adjunct professor at Columbia University’s Mailman School of Public Health, and Devi Sridhar of the University of Edinburgh. The duo have collaborated for a couple of years on broad scrutiny of the governance of global health, culminating in their recent publication, Governing Global Health: Who Runs the World and Why?  The speakers and participants discussed the prevailing dominance of the United States, United Kingdom, and Bill & Melinda Gates Foundation as the largest donors to global health institutions and the perverse impact this has on these organizations' self-determination. 

Finally, these times can be so overwhelming that it seems impossible to focus on valuable and important information amid the blizzard of jarring news. Here are some readings that I found interesting, presented in no particular order.

  • Susan Peschin, chief executive officer of the Alliance for Aging Research in Washington, went on a tear against Robert F. Kennedy Jr.’s anti-vaccine sentiments: “Your anti-vaccine crusade is a disgrace against science.”
 
  • Ruth J. Katz, director of the Health, Medicine, and Society Program at the Aspen Institute, penned a terrific defense of public health: “Strengthening public health doesn’t require dramatic scientific breakthroughs or elegant research. What it does take is strategic thinking, long-term vision, and the political will.”
 
  • A special issue of Vaccines provided a long list of studies reminding us that technology is not a solution in public health—delivery is the answer. Or as the lead editorial for the issue puts it, “No product, no program: The critical role of supply chains in closing the immunization gap.”
 
  • There is a puzzling surge in mumps cases across the United States and Australia. In the United States, outbreaks center around high schools and colleges. Why is this happening? Is it due to non-vaccination, viral evolution undermining the efficacy of existing vaccines, or perhaps manufacturing issues? Ed Silverman points at Merck’s no-comment stance about its mumps vaccines is cause for concern, and possibly a clue to cause.
 
  • For a decade, CFR has been tracking outbreaks of vaccine-preventable diseases and attacks on immunizers. In CFR’s vaccine-preventable outbreaks map (updated weekly), some striking trends have recently emerged, especially regarding pertussis, measles, and mumps. Give yourself a treat and take twenty minutes to navigate around the site by disease, region, or date. 
 

 

  • The Washington Post argues that President Trump’s planned cuts to the U.S. Agency for International Development, global health, and the State Department “will fundamentally undermine American national security. These types of proposed cuts will increase the likelihood that tens of thousands of people will starve to death. That’s not in American interests.”
 
  • Microbiome researchers estimate that 72 percent of all disease pathogenesis arises from within an individual’s microbiome. The bugs were there all along, but they evolved: “Our results show that infection, like a cancer of the microbiome, emerges through spontaneous adaptive evolution, raising new possibilities for diagnosis and treatment.”
 
  • The Group of Twenty finance ministers met and decided the world can ignore climate change—at least for the time being. The nations were taking their cue from Mick Mulvaney, Trump’s budget director, who told reporters, “We consider that to be a waste of [Americans’] money. I think the president is fairly straightforward. We’re not spending money on that.”
 
  • Annually, some twenty-seven million tons of spiders eat between 440 million and 880 million tons of insects. This carnivorous carnage includes consumption of vectors of infectious diseases.
 
  • Researchers have mapped the impact of climate change on human health across regions of the United States.
 
  • No one knows why (though climate change seems to be involved), but humpback whales are forming “super groups” of gatherings in the seas below South Africa—groups so large they can be seen from low-Earth orbit.
 
  • Everyone was wrong about evolution. Scientists have found that life started a lot longer in the past than previously believed. Plants? Science was wrong by 400 million years—and that is a lot. But the net clock reset on life on Earth could be one billion years further back in time.
 
  • Air pollution directly affects colonization of Streptococcus and Staphylococcus: “Our study highlights that air pollution has a significant effect on bacteria that has been largely overlooked. Consequently these findings have important implications concerning the impact of air pollution on human health and bacterial ecosystems worldwide.”
 
  • It was not the conquistadores that killed the Aztecs, but rather Salmonella, say Max Planck researchers.
 
  • Speaking of Mexico, the capital is sinking as overconsumption and climate change drain the lake below Mexico City.
 
  • India’s air pollution is causing about 1.1 million premature deaths per year, surpassing China as the country with the deadliest pollution in the world.
 
  • How bad is the Anthropocene? You can go deep—ten thousand meters to the bottom of the Mariana Trench—and find piles of plastics polluting the seas. “Contaminant levels were considerably higher than documented for nearby regions of heavy industrialization, indicating bioaccumulation of anthropogenic contamination and inferring that these pollutants are pervasive across the world’s oceans and to full ocean depth.”
 
 
  • Harvey M. Sapolsky of the Massachusetts Institute of Technology writes of the search for a new sense of world order and leadership in the post-Trump age:If not the United States in the lead then who? The alternatives are not robust.” And Elizabeth M. Speakman, Martin McKee, and Richard Coker argue, “If not now, when? Time for the European Union to define a global health strategy.”
 
  • The phrase “diseases of despair” caught on in medical literature a couple of years ago, but now it is appearing in the mainstream media as life expectancy for white, middle-class Americans declines. (The Greeks were way ahead of the United States on this one; reports of despair-associated death skyrocketed after the economic collapse.)
 
  •  In a stellar example of cross-national scientific research, a team of scientists from several countries published an exhaustive study in Science, “Biodiversity Redistribution Under Climate Change: Impacts on Ecosystems and Human Well-Being.” This study surveys species on the move worldwide in heating seas, acidifying streams, denuded forests, and drought-stricken expanses, and it is accompanied by a video explaining how these changes are affecting human health. An astounding supplemental table displays climate-associated effects on species all over the world. This material is not only must-read caliber, but it will undoubtedly form the basis of policy advocacy for years to come. It is, in short, an exhaustive, landmark work.
 

I was deeply honored to have been named a “Remarkable Woman of UC” and to learn that a plaque has been posted at the headquarters of the University of California.

As always, I will endeavor to keep you informed of developments in global health–related matters going forward. I will be attending the World Health Assembly and expect to tweet real-time observations as the meeting and director general election unfolds (@Laurie_Garrett).

Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations